Provider Demographics
NPI:1801956404
Name:KOONTZ, JAY D (DC)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:D
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:NORTH WEBSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46555-0579
Mailing Address - Country:US
Mailing Address - Phone:574-834-7855
Mailing Address - Fax:574-834-7935
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH WEBSTER
Practice Address - State:IN
Practice Address - Zip Code:46555
Practice Address - Country:US
Practice Address - Phone:574-834-7855
Practice Address - Fax:574-834-7935
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001901A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000210120OtherANTHEM BC BS
INU71212Medicare UPIN
IN189750Medicare ID - Type Unspecified